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PROSECU TOIL - <br />COIvmssiONERS `' <br />DEPART ENT --- - - <br />INSURANCE <br />Return to: <br />11/15/2017 03:47:56 PM 201711150066 <br />$0.00 Pawl of 8 <br />Claims Against County/rls/miso PROS <br />Kittitas County Auditor <br />11111111111111,1111111111111111111111111111111111111111111111111111111111111 <br />KITTITAS COUNTY CLAIM FOR DAMAGES <br />County Auditor <br />205 W 5th Ave, Suite 105 <br />Ellensburg, WA 98926 <br />509-962-7504 <br />Instructions: <br />Please read the entire form before completion. Fill out each question as completely as possible,. <br />to the best of your ability. Do not hesitate to use the back side of this form if you need more than <br />the space provided. An incomplete response may delay the processing of your claim. <br />Namg_fIncluding spouse, if married): <br />i a:L Peeb Ips <br />2. Phone (Home): ) (Work): (So9-�loa-7Dd O ) <br />3. Address (include former address if at present address for less than 6 months): <br />73DL S�Vnai-eu U gagD-k <br />Physical v -� <br />Mailing <br />4. Date of Birth: -7--D-14,9 <br />5. Date and Time of Incident: <br />iD-(ci - n e 6cl3o <br />6. Location of Incident: r p <br />KC -S () " 30-7 W cj-e, n 4—al a -m l <br />1 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 9/2012 <br />